1 Welcome Online Renewal Application Postgraduate Education To complete your renewal application, you must: 1. Answer all questions in this online application form 2. Pay online (or by alternate method) 3. If applicable: mail your renewed work permit and/or new statement of objectives (refer to your renewal notice for further details) Following submission of all above and our review of your application, an email confirming your renewal will be sent to you. NOTE: YOUR RENEWAL IS NOT COMPLETE UNTIL YOU RECEIVE OUR RENEWAL CONFIRMATION EMAIL. GENERAL INSTRUCTIONS: The purpose of this application form is to obtain information that is relevant to your annual registration for postgraduate training in Ontario. If you apply in the future for a certificate of registration authorizing Independent Practice, you will be asked questions relevant to your eligibility and suitability for independent practice in Ontario. This is an annual application form and the information you provide will be retained by the College. If you apply to renew your Postgraduate Education certificate next year, certain information you may provide in this year s form need not be re-submitted in next year s form. This form contains questions relating to adverse actions, offences, findings, and personal health. The College will review any yes response and, if necessary, will inquire further with you. Your prompt reply to our inquiries will expedite the review process. Before you start, make sure you have, o Approximately 20-30 minutes to complete the renewal process o Knowledge of the results of your annual BBP testing if you do Exposure Prone Procedures o Credit card information (Visa, MasterCard, American Express). We do not accept Visa Debit. The application will time out after 20 minutes if there is no activity. If you need any help while completing the form, please contact the College s Physician Advisory Service at 416-967-2603 or 1-800-268-7096, ext. 603, Mon-Fri, 8 am to 5 pm.
APPLICATION CONDITIONS: 1. No Delegation you must read all instructions and complete this form personally. No one can do it on your behalf. 2. Professional Misconduct It is professional misconduct to make a false or misleading report to the College. 3. Due Date Application Form for Renewal must be submitted by [date]. 4. Any information you provide may result in your application being referred to the College s Registration Committee. You may also be asked to provide additional information for clarification. 5. Scope of Information Your answers must reflect all of your practice experience. I acknowledge and understand the requirements for online application for renewal as outlined above. 2
3 Section 1 A. Contact Information: 1) Mailing Address 2) Email Address 3) Practice address <More Info> - Available to the Public - Provide one of the following: your training program address, hospital department address, or primary teaching site address. Section 2 B. Postgraduate Training Conduct/Leaves in ONTARIO Important! Before you respond, you must read this: <Important Information> The following questions ask about your enrolment, performance and conduct in your Ontario postgraduate medical training program. Note that the questions pertain to your training in ONTARIO only. They do not apply to your training completed outside Ontario, if any. If you do not fully understand a question or are uncertain how to answer, contact the College s Physician Advisory Service (see number at top of form). If you respond yes to any question in this section, you must provide an explanation below. The College may contact you for further information. 1) Have you ever been, or are you now, dismissed, suspended, removed, on probation, on involuntary leave, or otherwise denied, limited or restricted by an Ontario postgraduate medical training program or by an Ontario medical school where you were or are enrolled for postgraduate training? Note: if matter is under appeal, you must still answer yes. 2) Have you ever completed, or are you now completing, any postgraduate remedial training in Ontario for deficiencies or issues relating to professionalism, professional conduct,
4 professional attitudes, interpersonal skills or communication skills? Note: This question excludes remedial training required solely for deficiencies or issues in knowledge, clinical skills, or technical skills 3) Have you ever taken a leave of absence of 2 continuous years or longer from a postgraduate medical training program in Ontario, regardless of whether the leave was voluntary or was imposed by your training program or medical school? 4) Are you now on a leave of absence which has exceeded 2 years or may exceed 2 years in the coming training year, regardless of whether the leave was voluntary or was imposed by your training program or medical school? 5) Provide explanation(s) for any of your Yes responses in this section: C. Adverse Actions by Medical schools and other Institutions Important! Before you respond, you must read this: <Important Information> In this section, you are being asked to provide information about any adverse actions taken by 'Institutions' in relation to their Codes of Conduct, policies or guidelines which set out their expectations for conduct and behaviour. 'Institutions' means universities and medical schools in which you have been enrolled for postgraduate medical training, postgraduate medical training programs, hospitals, and other postgraduate teaching sites. Adverse action means any institutional action, consequence or outcome of an adverse nature in relation to your conduct, behaviour or professionalism. An adverse action includes but is not limited to, Official, formal written caution or reprimand Remedial action to address a behavioural or professionalism concern Restriction, probation, suspension, forced leave, dismissal or other penalty, sanction or disciplinary action
5 Examples of conduct or behaviour that might result in adverse actions by an Institution include, but are not limited to professionalism issues, such as: Absenteeism Plagiarism Dishonesty Breach of duty Disruptive behaviour, including inappropriate language, actions or behaviours Unethical behaviour Other violation of rules, expectations, boundaries, etc. If you respond yes to any question in this section, you must provide an explanation below. The College may contact you for further information. 1) Adverse Actions by ONTARIO institutions: a. Have you ever been subject to any adverse action by an ONTARIO Institution, the facts of which you have not previously disclosed to the College? b. Are there any adverse actions or other ongoing proceedings (i.e. matters not yet disposed of) against you by an ONTARIO Institution, the facts of which you have not previously disclosed to the College? c. Have you entered into an agreement with, or made a promise or given an undertaking to, an ONTARIO Institution in the face of potential adverse actions, the facts of which you have not previously disclosed to the College? 2) Adverse Actions by Institutions OUTSIDE Ontario: a. Have you ever been subject to any adverse action by an Institution outside Ontario, the facts of which you have not previously disclosed to the College? b. Are there any adverse actions or other ongoing proceedings (i.e. matters not yet disposed of) against you by an Institution outside Ontario, the facts of which you have not previously disclosed to the College? c. Have you entered into an agreement with, or made a promise or given an undertaking to, an Institution outside Ontario in the face of potential adverse actions the facts of which you have not previously disclosed to the College?
6 3) Provide explanation(s) for any of your Yes responses in this section: D. Registration in Other Jurisdictions < Important Information > - Identify all jurisdictions other than Ontario where you are licensed to practise medicine 1) Are you registered with any other medical licensing authorities other than Ontario? If yes, indicate the jurisdictions below [check boxes for provinces] Alberta Newfoundland & Labrador British Columbia Nova Scotia Manitoba Northwest Territories New Brunswick Nunavut Prince Edward Island Quebec Saskatchewan Yukon Outside Canada 2) Are you registered with any licensing authorities/regulators for other professions in Ontario or other jurisdictions? < Important Information > Examples of other licensing authorities/regulators may include but are not restricted to: - College of Nurses of Ontario - Ontario College of Pharmacists - Ontario College of Psychotherapists - Royal College of Dental Surgeons of Ontario - The Law Society of Upper Canada
7 3) Provide the names of the licensing authorities/regulators and their jurisdiction: Section 3 E. Disciplinary Actions in Other Jurisdictions Important! Before you respond, you must read this: < Important Information > The questions below ask about disciplinary actions by any licensing authority/regulator in any jurisdiction. Examples: - College of Physicians and Surgeons of Alberta - College of Pharmacists of British Columbia - Royal College of Dental Surgeons of Ontario - The Law Society of Upper Canada - College of Nurses of Nova Scotia If you respond yes to any question in this section, you must provide an explanation below. The College may contact you for further information. Answer all of the following questions: 1) Have you been disciplined by any licensing authority/regulator, the facts of which you have not previously disclosed to the College? 2) Are there disciplinary actions pending against you by any licensing authority/regulator, the facts of which you have not previously disclosed to the College? 3) Have you entered into an agreement with, or made a promise with or given an undertaking to, any licensing authority/regulator in the face of potential disciplinary action by the authority/regulator, the facts of which you have not previously disclosed to the College? 4) Provide explanation(s) for any of your Yes responses in this section:
8 F. Offences, Findings and Settlements Important! Before you respond, you must read this: < Important Information > Finding" means any judgement or decision made against you by a court in relation to any lawsuit involving a patient. This includes, but is not limited to, a finding of negligence, malpractice or battery. It also includes findings in which you have been found by the court to be liable for the acts of others, including your employees or agents, in a lawsuit involving a patient. Settlement" means an agreement to resolve a lawsuit involving a patient at any time during the proceeding. A settlement may or may not include payment made on your behalf to the patient or other parties in the lawsuit. You do not need to report a lawsuit that has been dismissed, discontinued, or withdrawn unless the lawsuit against you was dismissed, discontinued or withdrawn but included any payment of costs, admission of liability, and/or payment of money on behalf of the defence. Information in this section will not be made public except question 2. The College is required by legislation to publish every finding of professional negligence or malpractice on the public register, unless the finding is reversed on appeal. If you respond yes to any question in this section, you must provide an explanation below. The College may contact you for further information. Answer all of the following questions: 1) Have you ever been charged with any offence in Canada or elsewhere, the facts of which you have not previously disclosed to the College? Note: Include all offences under the Criminal Code of Canada, the controlled Drugs and Substances Act, the Food and Drugs Act or the Health Insurance Act or related legislation in any province or jurisdiction. In addition, include any other offences related to the practice of medicine. 2) Has a court ever made a finding against you in any lawsuit involving a patient or someone acting on behalf of a patient, the facts of which you have not previously disclosed to the College? 3) Have you ever made a settlement of any lawsuit involving a patient or someone acting on behalf of a patient, the facts of which you have not previously disclosed to the College?
9 4) Provide explanation(s) for any of your Yes responses in this section: G. Personal Health Status Answer all of the following questions: 1) Do you have an addiction or substance use problem (including alcohol) that may compromise your ability to practice medicine and for which you are not currently enrolled in the OMA's Physician Health Programme? 2) a) In the coming year of your postgraduate training program/practice, will you be performing, or will you be assisting in performing, exposure-prone procedures, or procedures that may become exposure-prone, as defined in the Blood Borne Pathogens policy? < Important Information > Important! Before you respond, you must read BBP Guidance (see page 12) b) If yes to (a), have you had your blood tested for Hepatitis B, Hepatitis C, and HIV within the last 12 months? i. If no, provide an explanation. The College may contact you for further information. c) If yes to (a), are you infected with or have you had a positive blood test with respect to Hepatitis B, Hepatitis C or HIV? Note: for Hepatitis B, if you test positive for the antibody only, answer No here i. If yes, provide an explanation. The College may contact you for further information.
10 Section 4 H. Professional Liability Protection You must have professional liability protection (e.g. CMPA) that complies with the College by-laws, unless you comply with the criteria for exemption. Make a declaration and select at least one of the options provided below: 1) I Declare that: I have professional liability protection that extends to all areas of my practice 2) If Yes to H(1), select all applicable: a) I have professional liability protection through the Canadian Medical Protective Association (CMPA) b) I have professional liability protection through a policy of professional liability insurance from an Ontario licensed company that provides coverage of at least $10 million. c) I have Canadian federal government coverage under the Treasury Board Policy on Legal Assistance and indemnification. d) I only provide medical service to other employees, not to any members of the public, and my employer s insurer will cover any professional liability claims made against me. 2) If No to H(1), select ONE: e) I currently practise medicine in Ontario but I do not have professional liability protection. i. If yes to 2(e), provide an explanation. The College may contact you for further information: f) I do not practise medicine in Ontario. <End of questions>
11 Application Submission You are ready to submit your responses for your Postgraduate Education Renewal Application. Responses cannot be changed once the application is submitted. To submit your responses, you must now complete 3 steps: Review your responses Complete the Acknowledgement and Certification below Pay online the renewal fee of $xxx.xx (or declare other method of payment). Review your responses: <Questions and your responses will be listed in summary form here> ACKNOWLEDGEMENT AND CERTIFICATION: I acknowledge that any information I provide may result in my application for renewal being referred to the College s Registration Committee for consideration as to whether I meet the registration requirements, and/or to the Inquiries, Complaints, and Reports Committee for consideration. I acknowledge I may also be asked to provide additional information for clarification. I am the member who completed and is submitting this 2015 Application Form for Renewal. I acknowledge that it is professional misconduct to make a false or misleading report to the College of Physicians and Surgeons of Ontario. I acknowledge that the College of Physicians and Surgeons may make inquiries to the Postgraduate Medical Education Office ( PGMEO ) of my Ontario medical school about the responses I have provided in this application. I authorize the PGMEO to provide information as required by the College. ONLINE PAYMENT OF FEE: <Payment instructions included here for payment by credit card, interac, etc.>
12 Guidance for Question G 2(a) Blood Borne Pathogens Policy The College s Blood Borne Pathogens policy requires physicians who do or assist in doing exposure-prone procedures (EPPs) to know their personal serologic status with regard to HIV, HBV and HCV. For more details, refer to the policy and to the frequently asked questions document: [link to policy and FAQ] Program-Specific Guidance for Postgraduate Trainees The following lists show which postgraduate training programs involve, or may involve, EPPS. (i.e. involve or may involve SHEA Cat III procedures or cases) If your coming year of training is in one of these programs -- or if your program includes any rotations or electives in one of these programs -- you should respond yes to question G 2(a). Regardless of whether you are a resident in Family Medicine or a resident in any other program, if your program in the coming year is expected to include rotations or electives in Obstetrics and Gynecology, other surgical specialty, Emergency Medicine or any discipline involving or possibly involving EPPs, you should respond yes to G 2(a). Note that this list is a guide only, not a definitive list. If your program or program rotations are not in this list and you are unsure whether they involve or may involve EPPS, check with your program director. If still uncertain, you should err on the side of caution and respond yes. Primary Specialties Involving EPPs Cardiac Surgery Cardiothoracic Surgery Cardiovascular and Thoracic Surgery Cardiovascular Surgery General Surgery Neurosurgery Sub-Specialties Involving EPPs Colorectal Surgery General Surgery Oncology Pediatric Surgery Thoracic Surgery Gynecologic Oncology Orthopedic Surgery Otolaryngology - Head and Neck Surgery Plastic Surgery Urology Vascular Surgery Obstetrics and Gynecology Emergency Medicine Gynecologic Reproductive Endocrinology and Infertility Maternal Fetal Medicine
13 Post-Certification Clinical Fellowship Programs Involving EPPs Cardiac Transplantation Endourology Hepatology/Liver Transplantation Transplantation Family Medicine - Obstetrics Trauma or Trauma General Surgery Urogynecology Family Medicine - Emergency Medicine Pediatric Neurosurgery Surgical Oncology